Methods for treating disorders or diseases associated with hyperlipidemia and hypercholesterolemia while minimizing side-effects

ABSTRACT

The present invention provides methods and compositions for treating hyperlipidemia and/or hypercholesterolemia comprising administering to the subject an effective amount of an MTP inhibitor to inhibit hyperlipidemia and/or hypercholesterolemia in said subject, wherein said administration comprises an escalating series of doses of the MTP inhibitor. In some embodiments the method comprises administering at least three step-wise, increasing dosages of the MTP inhibitor to the subject. In some embodiments, the method further comprises the administration of one or more other lipid modifying compounds.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. Ser. No. 16/727,036, filedDec. 26, 2019, which is a continuation of U.S. Ser. No. 16/030,703,filed Jul. 9, 2018, which is a continuation of U.S. Ser. No. 15/605,548,filed May 25, 2017, which is a continuation of U.S. Ser. No. 15/218,670,filed Jul. 25, 2016, which is a continuation of U.S. Ser. No.15/155,647, filed May 16, 2016, which is a continuation of U.S. Ser. No.14/959,756, filed Dec. 4, 2015, which is a continuation of U.S. Ser. No.14/075,483, filed Nov. 8, 2013, which is a continuation of U.S. Ser. No.13/046,118, filed Mar. 11, 2011, which is a continuation of U.S. Ser.No. 10/591,923, filed Jun. 21, 2007, which is a national phaseapplication under 35 U.S.C. § 371 of PCT/US05/007435 filed Mar. 7, 2005which in turn claims priority benefit of U.S. Ser. No. 60/550,915, filedMar. 5, 2004, all of which are hereby incorporated by reference in theirentireties.

FIELD OF THE INVENTION

The present invention generally relates to therapy forhypercholesterolemia and hyperlipidemia.

BACKGROUND OF THE INVENTION

Hypercholesterolemia is a well-known risk factor for ASCVD, the majorcause of mortality in the Western world. Numerous epidemiologicalstudies have clearly demonstrated that pharmacological lowering of totalcholesterol (TC) and Low-density Lipoprotein (LDL) Cholesterol (LDL-C)is associated with a significant reduction in clinical cardiovascularevents. Hypercholesterolemia is often caused by a polygenic disorder inthe majority of cases and modifications in lifestyle and conventionaldrug treatment are usually successful in reducing cholesterol levels.However, in few cases, as in familial hypercholesterolemia (FH), thecause is a monogenic defect and the available treatment in homozygouspatients can be much more challenging and far from optimal because LDL-Clevels remain extremely elevated despite aggressive use of combinationtherapy. Therefore, for this group of high-risk patients, effectivemedical therapy is urgently needed.

Triglycerides are common types of fats (lipids) that are essential forgood health when present in normal amounts. They account for about 95percent of the body's fatty tissue. Abnormally high triglyceride levelsmay be an indication of such conditions as cirrhosis of the liver,underactive thyroid (hypothyroidism), poorly controlled diabetes, orpancreatitis (inflammation of the pancreas). Researchers have identifiedtriglycerides as an independent risk factor for heart disease.

Higher-than-normal triglyceride levels are often associated with knownrisk factors for heart disease, such as low levels of HDL (“good”)cholesterol, high levels of LDL (“bad”) cholesterol and obesity.Triglycerides may also contribute to thickening of artery walls—aphysical change believed to be a predictor of atherosclerosis.

Therefore, high triglyceride levels are at least a warning sign that apatient's heart health may be at risk. In response, physicians may bemore likely to stress the importance of losing weight, getting enoughexercise, quitting smoking, controlling diabetes and other strategiesthat patients can use to protect their own cardiovascular health.

A large number of genetic and acquired diseases can result inhyperlipidemia. They can be classified into primary and secondaryhyperlipidemic states. The most common causes of the secondaryhyperlipidemias are diabetes mellitus, alcohol abuse, drugs,hypothyroidism, chronic renal failure, nephrotic syndrome, cholestasisand bulimia. Primary hyperlipidemias have also been classified intocommon hypercholesterolemia, familial combined hyperlipidemia, familialhypercholesterolemia, remnant hyperlipidemia, chylomicronemia syndromeand familial hypertriglyceridemia.

A number of treatments are currently available for lowering serumcholesterol and triglycerides. However, each has its own drawbacks andlimitations in terms of efficacy, side-effects and qualifying patientpopulation.

Bile-acid-binding resins are a class of drugs that interrupt therecycling of bile acids from the intestine to the liver; e.g.,cholestyramine (Questran Light®, Bristol-Myers Squibb), and colestipolhydrochloride (Colestid®, The Upjohn Company). When taken orally, thesepositively-charged resins bind to the negatively charged bile acids inthe intestine. Because the resins cannot be absorbed from the intestine,they are excreted carrying the bile acids with them. The use of suchresins, however, at best only lowers serum cholesterol levels by about20%, and is associated with gastrointestinal side-effects, includingconstipation and certain vitamin deficiencies. Moreover, since theresins bind other drugs, other oral medications must be taken at leastone hour before or four to six hours subsequent to ingestion of theresin; thus, complicating heart patient's drug regimens.

The statins are cholesterol-lowering agents that block cholesterolsynthesis by inhibiting HMGCoA reductase—the key enzyme involved in thecholesterol biosynthetic pathway. The statins, e.g., lovastatin(Mevacor®, Merck & Co., Inc.), simvastatin (Zocor®, Merck & Co., Inc.),atorvastatin (Lipitor®, Pfizer), rosuva (Crestor®, Astra Zeneca) andpravastatin (Pravachol®, Bristol-Myers Squibb Co.), and combinationsthereof, are sometimes used in combination with bile-acid-bindingresins. Statins significantly reduce serum cholesterol and LDL-serumlevels, and slow progression of coronary atherosclerosis. However, serumHDL cholesterol levels are only moderately increased. The mechanism ofthe LDL lowering effect may involve both reduction of VLDL concentrationand induction of cellular expression of LDL-receptor, leading to reducedproduction and/or increased catabolism of LDLs. Side effects, includingliver and kidney dysfunction are associated with the use of these drugs(Physicians Desk Reference, Medical Economics Co., Inc., Montvale, N.J.,2004; hereinafter “PDR”). The FDA has approved atorvastatin to treatrare but urgent cases of familial hypercholesterolemia.

Ezetimibe is a cholesterol absorption inhibitor which reduces the amountof cholesterol absorbed by the body. Ezetimibe is used to reduce theamount of total cholesterol, LDL cholesterol (by about 18%), andapolipoprotein B. Ezetimibe is often used with a low cholesterol dietand, in some cases, other cholesterol lowering medications.

Niacin, or nicotinic acid, is a water soluble vitamin B-complex used asa dietary supplement and antihyperlipidemic agent. Niacin diminishesproduction of VLDL and is effective at lowering LDL. In some cases, itis used in combination with bile-acid binding resins. NIASPAN® has beenapproved to prevent recurrent heart attacks in patients with highcholesterol. Niacin can increase HDL when used at adequate doses,however, its usefulness is limited by serious side effects when used atsuch high doses.

Fibric acid derivatives (“fibrates”) are a class of lipid-lowering drugsused to treat various forms of hyperlipidemia (i.e., elevated serumtriglycerides) which may also be associated with hypercholesterolemia.Fibrates appear to reduce the VLDL fraction and modestly increase HDL.However, the effects of these drugs on serum cholesterol is variable.Fibrates are mainly used to lower high triglyceride levels. Althoughfibrates typically do not appear as effective as statins in loweringtotal cholesterol and LDL cholesterol levels, they are sometimes used incombination with statins or other medications to lower very highcholesterol levels. For example, fibrates are also sometimes added tostatins to raise HDL cholesterol levels. In the United States, fibrateshave been approved for use as antilipidemic drugs, but have not receivedapproval as hypercholesterolemia agents. For example, clofibrate(Atromid-S®, Wyeth-Ayerst Laboratories) is an antilipidemic agent whichacts to lower serum triglycerides by reducing the VLDL fraction.Although serum cholesterol may be reduced in certain patientsubpopulations, the biochemical response to the drug is variable, and isnot always possible to predict which patients will obtain favorableresults. Atromid-S® has not been shown to be effective for prevention ofcoronary heart disease. The chemically and pharmacologically relateddrug, gemfibrozil (Lopid®, Parke-Davis) is a lipid regulating agentwhich moderately decreases serum triglycerides and VLDL cholesterol, andmoderately increases HDL cholesterol—the HDL₂ and HDL₃ subfractions aswell as both ApoA-I and A-II (i.e., the AI/AII-HDL fraction). However,the lipid response is heterogeneous, especially among different patientpopulations. Moreover, while prevention of coronary heart disease wasobserved in male patients between 40-55 without history or symptoms ofexisting coronary heart disease, it is not clear to what extent thesefindings can be extrapolated to other patient populations (e.g., women,older and younger males). Indeed, no efficacy was observed in patientswith established coronary heart disease. Fenofibrate (Tricor, Secalip)is also used to reduce levels of cholesterol and triglycerides. Seriousside-effects have been associated with the use of several fibratesincluding toxicity such as malignancy, (especially gastrointestinalcancer), gallbladder disease and an increased incidence in non-coronarymortality. Fibrates are often not indicated for the treatment ofpatients with high LDL or low HDL as their only lipid abnormality(Physician's Desk Reference, 2004, Medical Economics Co., Inc. Montvale,N.J.).

Oral estrogen replacement therapy may be considered for moderatehypercholesterolemia in post-menopausal women. However, increases in HDLmay be accompanied with an increase in triglycerides. Estrogen treatmentis, of course, limited to a specific patient population (postmenopausalwomen) and is associated with serious side effects including inductionof malignant neoplasms, gall bladder disease, thromboembolic disease,hepatic adenoma, elevated blood pressure, glucose intolerance, andhypercalcemia.

Homozygous familial hypercholesterolemia (hoFH) is a seriouslife-threatening genetic disease caused by homozygosity or compoundheterozygosity for mutations in the low density lipoprotein (LDL)receptor. Total plasma cholesterol levels are generally over 500 mg/dland markedly premature atherosclerotic vascular disease is the majorconsequence. Untreated, most patients develop atherosclerosis before age20 and generally do not survive past age 30. The primary goal of therapyconsists of controlling the hypercholesterolemia to delay thedevelopment of atherosclerotic cardiovascular disease (ASCVD). However,patients diagnosed with hoFH are largely unresponsive to conventionaldrug therapy and have limited treatment options. A mean LDL-C reductionof only about 5.5% has been recently reported in patients withgenotype-confirmed hoFH treated with the maximal dose of statins(atorvastatin or simvastatin 80 mg/day). The addition of ezetimibe 10mg/day to this regimen resulted in a total reduction of LDL-C levels of27%, which is still far from optimal. Several non-pharmacologicaloptions have also been tested. Surgical interventions, such asportacaval shunt and ileal bypass have resulted only in partial andtransient LDL-C lowering. Orthotopic liver transplantation has beendemonstrated to substantially reduce LDL-C levels in hoFH patients, butobvious disadvantages and risks are associated with this approach.Although hoFH could be an excellent model for gene therapy, thismodality of treatment is not foreseeable in the near future due to thelimitations on the availability of safe vectors that provide long-termexpression of LDL receptor gene. Thus, the current standard of care inhoFH is LDL apheresis, a physical method of filtering the plasma ofLDL-C which as monotherapy can transiently reduce LDL-C by about 50%.Apheresis uses affinity columns to selectively remove apoB-containinglipoproteins. However, because of rapid re-accumulation of LDL-C inplasma, apheresis has to be repeated frequently (every 1-2 weeks) andrequires 2 separate sites for IV access. Although anecdotally thisprocedure may delay the onset of atherosclerosis, it is laborious,expensive, and not readily available. Furthermore, although it is aprocedure that is generally well tolerated, the fact that it needsfrequent repetition and IV access can be challenging for many of theseyoung patients. Therefore, there is a tremendous unmet medical need fornew medical therapies for hoFH.

Patients with heterozygous FH can usually be successfully treated withcombination drug therapy to lower the LDL-C to acceptable levels. Incontrast, hoFH is unresponsive to conventional drug therapy and thusthere are limited treatment options. Specifically, treatment withstatins, which reduce LDL-C by inhibiting cholesterol synthesis andupregulating the hepatic LDL receptor, have negligible effect inpatients whose LDL receptors are non-existent or defective.

In July 2004, the NCEP published a paper entitled “Implications ofRecent Clinical Trials for the National Cholesterol Education ProgramAdult Treatment Panel III Guidelines”, updating certain elements of the“Adult Treatment Panel III (ATP III)” cholesterol guidelines released in2001. For high-risk patients, individuals who have coronary heartdisease (CHD) or disease of the blood vessels to the brain orextremities, or diabetes, or multiple (2 or more) risk factors that givethem a greater than 20 percent chance of having a heart attack within 10years, the ATP III update recommends that the overall goal for high-riskpatients is still an LDL less than 100 mg/dL with a therapeutic optionto set the goal at an LDL less than 70 mg/dL for very high-riskpatients, those who have had a recent heart attack, or those who havecardiovascular disease combined with either diabetes, or severe orpoorly controlled risk factors (such as continued smoking), or metabolicsyndrome (a cluster of risk factors associated with obesity thatincludes high triglycerides and low HDL cholesterol). The ATP III updatealso recommends consideration of drug treatment in addition to lifestyletherapy for LDL levels 100 mg/dL or higher in high-risk patients, andcharacterizes drug treatment as optional for LDL less than 100 mg/dL.For moderately high-risk patients, individuals who have multiple (2 ormore) CHD risk factors together with a 10-20 percent risk for a heartattack within 10 years, the ATP III update recommends the overall goalfor moderately high-risk patients to be an LDL less than 130 mg/dL.There is a therapeutic option to set the treatment goal at an LDL lessthan 100 mg/dL, and to use drug treatment if LDL is 100-129 mg/dL. Forhigh-risk and moderately high-risk patients, the ATP III update advisesthat the intensity of LDL-lowering drug treatment in high-risk andmoderately high-risk patients be sufficient to achieve at least a 30percent reduction in LDL levels.

Patients suffering from severe hypercholesterolemia may also be unableto reach the new goals for LDL and HDL described above. For example, alarge number of patients may be unable to attain LDL levels less than 70using maximally tolerated current methodologies.

Abetalipoproteinemia is a rare genetic disease characterized byextremely low cholesterol and TG levels, absent apolipoprotein (apo)B-containing lipoproteins in plasma, fat malabsorption, severe vitamin Edeficiency, and progressive spinocerebellar and retinal degeneration. Ithas been determined that mutations in the MTP were the genetic cause ofabetalipoproteinemia. MTP is responsible for transferring lipids,particularly TG, onto the assembling chylomicron and VLDL particles inthe intestine and the liver, respectively. Although the mechanisms bywhich lipoproteins are formed are not completely understood, it iscurrently believed that the assembly of apoB containing lipoproteinsrequires two steps. The first step occurs within the endoplasmicreticulum that involves the synthesis of particles that contain only asmall fraction of the lipid core found in the secreted lipoprotein. Alarger core of lipid is added to the nascent particle in a second step.MTP is thought to be essential for the transfer of lipid to the apoBduring the first step of the process. In the absence of functional MTP,chylomicrons and VLDL are not effectively assembled or secreted in thecirculation and apoB is likely targeted for degradation. VLDL serves asthe metabolic precursor to LDL and the inability to secrete VLDL fromthe liver results in the absence of LDL in the blood. The concept thatMTP may regulate apoB lipoprotein assembly is supported by observationsin mice models. In heterozygous knockout mice MTP mRNA, protein andactivity have been reported approximately half of normal and the apoBplasma concentration was reduced about 30%. Dramatic reduction ofapoB-100 concentration in plasma was also seen in liver-specific MTPknockout mice. The finding that MTP is the genetic cause ofabetaliproteinemia and that is involved in apoB-containing particlesassembly and secretion led to the concept that pharmacologic inhibitionof MTP might be a successful strategy for reducing atherogeniclipoproteins levels in humans.

Because of the tremendous impact on the treatment of atherosclerosis andcardiovascular disease that can be derived from the pharmacologicinhibition of hepatic secretion of apoB containing lipoproteins, severalMTP inhibitors have been developed. Both in vitro and in vivo animalstudies with these compounds support the concept that inhibition of MTPresults in inhibition of apoB containing lipoproteins secretion andconsequent reduction of plasma cholesterol levels. Interestingly, theanimal studies cited above had been conducted in Watanabe-heritablehyperlipidemic (WHHL) rabbits and LDLR−/− mice, two models for hoFH.

Bristol-Myers Squibb (BMS) developed a series of compounds, includingBMS-201038, as potent inhibitors of MTP-mediated neutral lipid transferactivity. These compounds are described, for example, in U.S. Pat. Nos.5,789,197, 5,883,109, 6,066,653, and 6,492,365, each of which isincorporated herein by reference in its entirety. MTP inhibitors aredescribed throughout U.S. Pat. No. 6,066,653, in particular in columns3-28. In in vitro studies, BMS-201038 appears to inhibit lipid transferby directly binding to MTP. In cell culture studies, the IC₅₀ forinhibition of apoB secretion by BMS-201038 was much lower than that forapoAI secretion (0.8 nM vs 6.5 μM), indicating that the compound is ahighly selective inhibitor of apoB secretion. The efficacy to inhibitaccumulation of triglyceride-rich particles in plasma of rats afterinjection of Triton is similar in both fed and fasted states, suggestingthat both intestinal and hepatic lipoprotein secretions are inhibited bythis compound. Six-month toxicity studies were conducted by BMS in ratsand dogs and their results are detailed in IND #50,820. Doses testedwere 0, 0.02, 0.2, 2.0, and 20 mg/kg in rats and 0, 0.01, 0.1, 1.0, and10 mg/kg in dogs. Dose-related lipid accumulation in the liver and smallintestine correlated with decrease in serum TG and cholesterol levels.These changes are a consequence of the pharmacologic effects ofBMS-201038. In rats, but not in dogs, doses of 0.2 mg/kg and higher wereassociated with subacute inflammation and single-cell necrosis ofhepatocytes and histiocytosis (phospholipidosis) in the lungs. Thehepatic accumulation of lipids was reversed in rats at the end of a1-month washout period. Studies in animals indicated that BMS-201038effectively reduced plasma cholesterol levels in a dose dependent mannerBMS-201038 was found to be effective in reducing cholesterol levels inrabbits that lack a functional LDL receptor: The ED₅₀ value for loweringcholesterol was 1.9 mg/kg and a dose of 10 mg/kg essentially normalizedcholesterol levels with no alteration in plasma AST or ALT. This study,conducted in the best accepted animal model for the homozygous FH,indicated that MTP inhibition by BMS-201038 might be effective insubstantially reducing cholesterol levels in patients with hoFH.

Clinical development of BMS-201038 as a drug for large scale use in thetreatment of hypercholesterolemia has been discontinued, because ofsignificant and serious hepatotoxicities. For example, gastrointestinalside effects, elevation of serum transaminases and hepatic fataccumulation were observed, primarily at 25 mg/day or higher doses.Thus, there is a need to develop methods for treating hyperlipidemiaand/or hypercholesterolemia that are efficacious in lowering serumcholesterol and LDL, increasing HDL serum levels, preventing coronaryheart disease, and/or treating diseases associated with hyperlipidemiaand/or hypercholesterolemia, without the side-effects associated withknown treatments.

SUMMARY OF THE INVENTION

The present invention relates to methods of treating disordersassociated with hypercholesterolemia and/or hyperlipidemia.

In some embodiments the invention relates to methods of treating asubject suffering from a disorder associated with hyperlipidemia and/orhypercholesterolemia. The methods comprise administering to the subjectan amount of an MTP inhibitor effective to ameliorate the disorder,wherein said administration comprises at least three step-wise,increasing dosages of the MTP inhibitor. In some embodiments the MTPinhibitor has the structure:

or a pharmaceutically acceptable salt thereof or the piperidine N-oxidethereof.

The present invention further provides methods for inhibiting MTP in asubject in need thereof. The methods comprise administering to thesubject an amount of an MTP inhibitor effective to inhibit MTP, whereinsaid administration comprises at least three step-wise, increasingdosages of the MTP inhibitor.

The present invention provides kits for treating a disorder associatedwith hyperlipidemia and/or hypercholesterolemia in a subject, comprisingat least three sets of pharmaceutical dosage units; and instructions foruse.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is based on the surprising discovery that one maytreat an individual who has hyperlipidemia and/or hypercholesterolemiawith an MTP inhibitor in a manner that results in the individual notexperiencing side-effects normally associated with the inhibitor, orexperiencing side-effects to a lesser degree. Accordingly, the presentinvention provides methods of treating a subject suffering from adisorder associated with hyperlipidemia while reducing side-effects, themethod comprising the step of administering to the subject an effectiveamount of the MTP inhibitor to ameliorate hyperlipidemia and/orhypercholesterolemia in the subject according to a treatment regimenthat reduces and/or eliminates side-effects associated with the use ofthe inhibitors.

By “treatment” is meant at least an amelioration of the symptomsassociated with the pathological condition afflicting the host as wellas an amelioration of the side-effects associated with the MTP inhibitorseen in patients treated in accordance with traditional treatmentregimens making use of MTP inhibitors. “Amelioration” is used in a broadsense to refer to at least a reduction in the magnitude of a parameter,e.g. symptom, associated with the pathological condition being treated,such as elevated plasma VLDL or triglyceride levels, or with a sideeffect of treatment using the inhibitor, such as GI side-effects orhepatobiliary side-effects. As such, treatment also includes situationswhere the pathological condition, or at least symptoms associatedtherewith, are completely inhibited, e.g. prevented from happening, orstopped, e.g. terminated, such that the host no longer suffers from thepathological condition, or at least the symptoms that characterize thepathological condition, e.g. plasma VLDL and/or triglyceride levels arereturned to normal.

The present invention also provides methods of treatingdiseases/disorders associated with hypercholesterolemia and/orhyperlipidemia comprising administering to a subject an MTP inhibitorand a further lipid modifying compound. The methods reduce and/oreliminate side-effects associated with the use of MTP inhibitors.

As used herein, the phrase “disorders associated with hyperlipidemiaand/or hypercholesterolemia” refers to diseases and disorders related toor caused by elevated lipid or cholesterol levels. Such diseases anddisorders include, without limitation, hypercholesterolemia, severehypercholesterolemia, familial combined hyperlipidemia, familialhypercholesterolemia, remnant hyperlipidemia, chylomicronemia syndromeand familial hypertriglyceridemia. In some embodiments, the disease issevere hypercholesterolemia. In some embodiments, the disease ishomozygous/heterozygous familial hypercholesterolemia. In someembodiments the disease is hypertriglyceridemia.

Microsomal triglyceride transfer protein (MTP) is known to catalyze thetransport of triglyceride and cholesteryl ester by preference tophospholipids such as phosphatidylcholine. It was demonstrated by D.Sharp et al., Nature (1993) 365:65 that the defect causingabetalipoproteinemia is in the MTP gene. This indicates that MTP isrequired for the synthesis of Apo B-containing lipoproteins such asVLDL, the precursor to LDL. It therefore follows that an MTP inhibitorwould inhibit the synthesis of VLDL and LDL, thereby lowering levels ofVLDL, LDL, cholesterol and triglyceride in humans.

MTP inhibitors belong to the class of polyarylcarboxamides. MTPinhibitors, methods of use and preparation thereof are known to the artskilled and are described, inter alia, in WO 96/26205; U.S. Pat. No.5,760,246; WO 96/40640; WO-98/27979. Canadian Patent Application Ser.No. 2,091,102, U.S. application Ser. No. 117,362, WO 92/26205 publishedAug. 29, 1996, U.S. application Ser. No. 472,067, filed Jun. 6, 1995,U.S. application Ser. No. 548,811, filed Jan. 11, 1996, U.S. provisionalapplication Ser. No. 60/017,224, filed May 9, 1996, U.S. provisionalapplication Ser. No. 60/017,253, filed May 10, 1996, U.S. provisionalapplication Ser. No. 60/017,254, filed May 10, 1996, U.S. provisionalapplication Ser. No. 60/028,216, filed Oct. 1, 1996, U.S. Pat. Nos.5,595,872, 5,789,197, 5,883,109, and 6,066,653. All of the above,including structures, are incorporated herein by reference.

Pharmacologic inhibition of MTP with Bristol-Myers Squibb's BMS-201038,a potent inhibitor of MTP, has been shown to reduce low densitylipoprotein cholesterol (LDL-C) by up to 65% in healthy volunteers withhypercholesterolemia. Despite these impressive LDL-C reductions,steatorrhea, elevation of serum transaminases and hepatic fataccumulation were observed, primarily at 25 mg/day or higher doses.Thus, Bristol-Myers Squibb decided that these side effects made itunlikely that BMS-201038 could be developed as a drug for large scaleuse in the treatment of hypercholesterolemia. Combinations using MTPinhibitors and other cholesterol or triglyceride drugs have beenpreviously disclosed (U.S. Pat. Nos. 6,066,653 and 5,883,109) but sufferthe same drawbacks as described above for MTP inhibitors used alone.

In some embodiments the MTP inhibitors are piperidine, pyrrolidine orazetidine compounds. In some embodiments, the MTP inhibitor has astructure as set forth in U.S. Pat. No. 6,066,653. In some embodimentsthe MTP inhibitor is9-[4-[4-[[2-(2,2,2-trifluoromethyl)-benzoyl]amino]-1-piperidinyl]butyl]-N-(2,2,2-trifluoroethyl)-9H-fluorene-9-carboxamide.In some embodiments, the MTP inhibitor is BMS-201038. As used herein,the phrase “BMS-201038” refers to a compound known asN-(2,2,2-Trifluorethyl)-9-[4-[4-[[[4′-(trifluoromethyl)[1,1′biphenyl]-2-Y1]carbonyl]amino]-1-piperidinyl]butyl]9H-fluorene-9-carboxamide,methanesulfonate, having the formula:

or a pharmaceutically acceptable salt thereof or the piperidine N-oxidethereof.

In some embodiments, MTP activity is inhibited by 10%, 20%, 25%, 30%,40%, 50%, 60%, 70%, 75%, 80, 90%, 95%, or 100% compared to a MTPactivity in an untreated or control subject. Methods for testing forinhibition of MTP activity are known to those of skill in the art andare set forth, for example, in U.S. Pat. No. 5,789,197.

As used herein, the phrase “untreated or control subject” refers to asubject who has not been administered an MTP inhibitor in at least threestep-wise, increasing dosages.

In some embodiments, the methods further comprise the administration ofother lipid modifying compounds. As used herein, the phrase “lipidmodifying compounds” and the like, refers to medicaments for treatingdisorders associated with hypercholesterolemia and/or hyperlipidemiausing standard dosing, e.g. a treatment not including at least threestep-wise, increasing dosages of an MTP inhibitor. Lipid modifyingcompounds which may be used in the method of the invention include,without limitation, HMG CoA reductase inhibitors, cholesterol absorptioninhibitors, ezetimide, squalene synthetase inhibitors, fibrates, bileacid sequestrants, statins, probucol and derivatives, niacin, niacinderivatives, PPAR alpha agonists, fibrates, PPAR gamma agonists,thiazolidinediones, and cholesterol ester transfer protein (CETP)inhibitors.

HMG CoA reductase inhibitors suitable for use herein include, but arenot limited to, mevastatin and related compounds as disclosed in U.S.Pat. No. 3,983,140, lovastatin (mevinolin) and related compounds asdisclosed in U.S. Pat. No. 4,231,938, pravastatin and related compoundssuch as disclosed in U.S. Pat. No. 4,346,227, simvastatin and relatedcompounds as disclosed in U.S. Pat. Nos. 4,448,784 and 4,450,171, withpravastatin, lovastatin or simvastatin being preferred. Other HMG CoAreductase inhibitors which may be employed herein include, but are notlimited to, fluvastatin, rosuva, cerivastatin, atorvastatin, pyrazoleanalogs of mevalonolactone derivatives as disclosed in U.S. Pat. No.4,613,610, indene analogs of mevalonolactone derivatives as disclosed inPCT application WO 86/03488,6-[2-(substituted-pyrrol-1-yl)alkyl]pyran-2-ones and derivatives thereofas disclosed in U.S. Pat. No. 4,647,576, Searle's SC-45355 (a3-substituted pentanedioic acid derivative) dichloroacetate, imidazoleanalogs of mevalonolactone as disclosed in PCT application WO 86/07054,3-carboxy-2-hydroxy-propane-phosphonic acid derivatives as disclosed inFrench Patent No. 2,596,393, 2,3-di-substituted pyrrole, furan andthiophene derivatives as disclosed in European Patent Application No.0221025, naphthyl analogs of mevalonolactone as disclosed in U.S. Pat.No. 4,686,237, octahydronaphthalenes such as disclosed in U.S. Pat. No.4,499,289, keto analogs of mevinolin (lovastatin) as disclosed inEuropean Patent Application No. 0,142,146 A2, as well as other known HMGCoA reductase inhibitors. In addition, phosphinic acid compounds usefulin inhibiting HMG CoA reductase suitable for use herein are disclosed inGB 2205837.

Squalene synthetase inhibitors suitable for use herein include, but arenot limited to, α-phosphonosulfonates disclosed in U.S. application Ser.No. 08/266,888, filed Jul. 5, 1994 (HX59b), those disclosed by Biller etal, J. Med. Chem. 1988, Vol. 31, No. 10, pp 1869-1871, includingisoprenoid (phosphinylmethyl)phosphonates including the triacidsthereof, triesters thereof and tripotassium and trisodium salts thereofas well as other squalene synthetase inhibitors disclosed in U.S. Pat.Nos. 4,871,721 and 4,924,024 and in Biller et al, J. Med. Chem., 1988,Vol. 31, No. 10, pp 1869 to 1871.

In addition, other squalene synthetase inhibitors suitable for useherein include the terpenoid pyrophosphates disclosed by P. Ortiz deMontellano et al, J. Med. Chem.; 1977, 20, 243-249, the famesyldiphosphate analog A and presqualene pyrophosphate (PSQ-PP) analogs asdisclosed by Corey and Volante, (J. Am. Chem. Soc. 1976, 98, 1291-1293),phosphinylphosphonates reported by McClard, R. W. et al, (J.A.C.S.,1987, 109, 5544) and cyclopropanes reported by Capson, T. L., (PhDdissertation, June, 1987, Dept. Med. Chem. U. of Utah, Abstract, Tableof Contents, pp. 16, 17, 40-43, 48-51, Summary) In some embodiments theinhibitor is pravastatin, lovastatin or simvastatin.

Peroxisome proliferator activated receptor-alpha (PPAR-alpha) andPPAR-gamma agonists, fibrates, thiazolidinediones and CETP inhibitorsare well known to those skilled in the art.

The present invention provides methods for treating diseases ordisorders associated with hyperlipidemia and/or hypercholesterolemiawhile minimizing side-effects ordinarily associated with the use of suchinhibitors. In some embodiments, the inhibitor is an MTP inhibitorhaving the structure:

In some embodiments, one or more of total cholesterol levels, plasmaLDL-cholesterol levels, triglyceride levels, fasting triglycerides (TG)levels, VLDL levels, lipoprotein (a) (Lp(a)) levels, or ApolipoproteinsA-I, A-II, B, and E levels in the subject are reduced by at least 15%,by at least 25%, at least 30%, at least 40%, at least 50%, at least 60%,at least 70%, at least 75%, or at least 80% compared to control bloodlevels.

In some embodiments, triglyceride levels achieved are less than 500mg/dl. In some embodiments, triglyceride levels achieved are less than300 mg/dl. In some embodiments, triglyceride levels achieved are lessthan 200 mg/dl. In some embodiments, triglyceride levels achieved areless than 150 mg/dl.

In some embodiments, the ApoB/ApoA1 ratio achieved by treatmentaccording to the present invention is from 0.25 to 1.25. In someembodiments the ApoB/ApoA1 ratio achieved is from 0.1 to 2.0. In someembodiments the apoB level achieved is from 48-130. In some embodimentsthe apoB level achieved is from 20-180.

As used herein, the phrase “control blood levels” refers to a level of aparticular blood component in the absence of treatment according to thepresent invention. In some embodiments, the “control blood level” is thelevel of a particular blood component in the subject prior to treatmentof the subject according to the present invention. In some embodiments,the “control blood level” is the level of a particular blood componentif a subject either receiving a placebo or receiving a differenttreatment; e.g. a treatment not including at least three step-wise,increasing dosages of an MTP inhibitor. Reduction of levels of bloodcomponents, including, for example, cholesterol, triglycerides, andapolipoprotein B, can be determined by comparing pre-treatment levels tolevels during or after treatment according to the present invention.Methods of measuring levels of particular components of blood arewell-known to those of skill in the art. For example, total plasmacholesterol and triglyceride concentrations may be determined by amodification of the Liebermann-Burchard reaction (Abell L L, Levy B B,Brodie B B, Kendall F E. A simplified method for the estimation of totalcholesterol in serum and demonstration of its specificity. J Biol Chem.1952; 195:357-362) and by the method of Kessler and Lederer afterzeolite extraction, (Kessler G, Lederer H. Fluorometric measurement oftriglycerides. In: Skeggs L T, Jr, eds. Automation in AnalyticalChemistry: Technicom Symposia. New York, N.Y.: Madiad Inc;1965:341-344), respectively. Plasma HDL cholesterol may be estimated bythe method of Allain et al (Allain C C, Poon L S, Chan G S G, RichmondW, Fu P C. Enzymatic determination of total serum cholesterol. ClinChem. 1974; 20:470-475) using an enzymatic kit (Biotrol). LDLcholesterol may be calculated using the Freidewald formula. (FreidewaldW T, Levy R I, Fredrickson D S. Estimation of the concentration of lowdensity lipoprotein-cholesterol in plasma without the use of thepreparative ultracentrifuge. Clin Chem. 1972; 18:499-502). Plasma apoB,apoA1, and lipoprotein(a) levels may be measured by immunological assaysas described earlier (Guo H, Chapman M J, Bruckert E, Farriaux J P, DeGennes J L. Lipoprotein Lp(a) in homozygous familialhypercholesterolemia: density profile, particle heterogeneity andapolipoprotein(a) phenotype. Atherosclerosis. 1991; 31:69-83) and basedon laser immunonephelometry (Immuno AG).

In some embodiments, the subject is a mammal, preferably a human. Insome embodiments, the subject has proven refractory to previoustreatment regimens.

The MTP inhibitors of the present invention may be used alone oroptionally in combination with other lipid modifying compounds and maybe administered systemically, such as orally or parenterally ortransdermally, to subjects in need of treatment. The dosages andformulations for the other lipid modifying compounds to be employed,where applicable, will be as set out in the latest edition of thePhysicians' Desk Reference.

As used herein, the term “susceptible” refers to patients who suffer oneor more side-effects when MTP inhibitors are administered to them usingtraditional treatment regimens in an attempt to amelioratehypercholesterolemia and/or hyperlipidemia.

As used herein, the phrase “traditional treatment regimens” and thelike, refers to methods of treating hypercholesterolemia and/orhyperlipidemia using standard dosing, e.g. a treatment not including atleast three step-wise, increasing dosages of an MTP inhibitor.

Although not wishing to be bound by theory, it is thought that theadministration of MTP inhibitors in accordance with the methods of thepresent invention, in combination with one or more other lipid modifyingcompounds may further reduce undesired levels of cholesterol or lipidsand/or reduce undesired side-effects of the MTP inhibitor or undesiredside-effects of the MTP inhibitor and the other lipid modifyingcompounds.

In some embodiments, the MTP inhibitor is administered at escalatingdoses. In some embodiments, the escalating doses comprise at least afirst dose level and a second dose level. In some embodiments, theescalating doses comprise at least a first dose level, a second doselevel, and a third dose level. In some embodiments, the escalating dosesfurther comprise a fourth dose level. In some embodiments, theescalating doses comprise a first dose level, a second dose level, athird dose level, a fourth dose level and a fifth dose level. In someembodiments, six, seven, eight, nine and ten dose levels arecontemplated.

In some embodiments, each dose level is no more than 50% of theimmediately following dose level. In some embodiments, each dose levelis no more than 33% of the immediately following dose level. In someembodiments, each dose level is no more than 20% of the immediatelyfollowing dose level. In some embodiments, dose levels are separated by½ log units. In some embodiments, dose levels are separated by 1 logunit.

In some embodiments, the first dose level is from about 0.02 to about0.059 mg/kg/day. In some embodiments, second dose level is from about0.06 to about 0.19 mg/kg/day. In some embodiments, the third dose levelis from about 0.2 to about 0.59 mg/kg/day. In some embodiments, thefourth dose level is from about 0.6 to about 2.0 mg/kg/day.

In some embodiments the MTP inhibitor is administered to the subject at:

(a) 0.03 mg/kg/day for a first interval;

(b) 0.1 mg/kg/day for a second interval;

(c) 0.3 mg/kg/day for a third interval; and

(d) 1.0 mg/kg/day for a fourth interval.

In some embodiments the first, second, third, and fourth dose levels areadministered to the subject for from about 2 days to about 6 months induration. In some embodiments the first, second, third, and fourth doselevels are administered to the subject for from about 7 days to about 35days in duration. In some embodiments the first, second, third, andfourth dose levels are administered to the subject for from about 2weeks to about 4 weeks in duration. In some embodiments the first,second, third, and fourth dose levels are administered to the subjectfor about 4 weeks. In some embodiments the first, second, third doselevels are administered to the subject for from about 2 days to about 40days and the fourth dose level is administered to the subject for fromabout 2 days to about 6 months.

In some embodiments, the first dose level is from about 2 to about 30mg/day. In some embodiments, the second dose level is from about 20 toabout 50 mg/day. In some embodiments, the third dose level is from about30 to about 60 mg/day. In some embodiments, the fourth dose level isfrom about 40 to about 75 mg/day. In some embodiments, the fifth doselevel is from about 50 to about 75 mg/day.

In some embodiments, the first dose level is from about 2 to about 13mg/day. In some embodiments, the second dose level is from about 5 toabout 30 mg/day. In some embodiments, the third dose level is from about10 to about 50 mg/day. In some embodiments, the fourth dose level isfrom about 20 to about 60 mg/day. In some embodiments, the fifth doselevel is from about 30 to about 75 mg/day.

In some embodiments the first dose level is 6.25 mg/day, the second doselevel is 12.5 mg/day, and the third dose level is 50 mg/day.

In some embodiments the first dose level is about 12.5 mg/day. In someembodiments, the second dose level is about 25 mg/day. In someembodiments, the third dose level is from about 37.5 mg/day. In someembodiments, the fourth dose level is about 50 mg/day.

In some embodiments the first dose level is about 25 mg/day. In someembodiments, the second dose level is about 37.5 mg/day. In someembodiments, the third dose level is from about 50 mg/day. In someembodiments, the fourth dose level is about 75 mg/day.

In some embodiments the methods comprise the administration of five ormore escalating doses to the subject. In some embodiments the first doselevel is 6.25 mg/day, the second dose level is 12.5 mg/day, the thirddose level is 25 mg/day, the fourth dose level is 37.5 mg/day, and thefifth dose level is 50 mg/day.

In some embodiments each dose level is administered to the subject forfrom 2 days to 26 weeks. In some embodiments each dose level isadministered to the subject for from about 1 week to about 26 weeks. Insome embodiments each dose level is administered to the subject for fromabout 1 week to about 12 weeks. In some embodiments, each dose level isadministered to the subject for 1 week to 5 weeks. In some embodimentseach dose level is administered to the subject from 1 to 4 weeks. Insome embodiments each dose level is administered to the subject from 1to 2 weeks. In some embodiments each dose level is administered to thesubject from 1 to 2 weeks.

In some embodiments the first dose level is administered to the subjectfor 1 week, the second dose level is administered to the subject for 1week, and the third dose level is administered to the subject for 1week.

In some embodiments the first dose level is administered to the subjectfor 2 weeks, the second dose level is administered to the subject for 2weeks, and the third dose level is administered to the subject for 2weeks.

In some embodiments, the other lipid modifying compounds areadministered according to traditional treatment regimens. In someembodiments, the lipid modifying compounds are administered atescalating doses. In some embodiments, the lipid modifying compounds areadministered to the subject in least three step-wise, increasingdosages.

As used herein, the phrase “minimizing side effects” refers to anamelioration or elimination of one or more undesired side effects of theMTP inhibitors of the present invention.

As used herein, the phrase “side effects” refers to undesired eventsoccurring as a result of the traditional use of the inhibitors of theinvention. “Side effects” of traditional use of the MTP inhibitorsinclude, without limitation, steatorrhea, abdominal cramping,distention, elevated liver function tests, fatty liver; hepatic fatbuild up, polyneuropathy, peripheral neuropathy, rhabdomyolysis,arthralgia, myalgia, chest pain, rhinitis, dizziness, arthritis,peripheral edema, gastroenteritis, liver function tests abnormal,colitis, rectal hemorrhage, esophagitis, eructation, stomatitis, biliarypain, cheilitis, duodenal ulcer, dysphagia, enteritis, melena, gumhemorrhage, stomach ulcer, tenesmus, ulcerative stomatitis, hepatitis,pancreatitis, cholestatic jaundice, paresthesia, amnesia, libidodecreased, emotional lability, incoordination, torticollis, facialparalysis, hyperkinesia, depression, hypesthesia, hypertonia, legcramps, bursitis, tenosynovitis, myasthenia, tendinous contracture,myositis, hyperglycemia, creatine phosphokinase increased, gout, weightgain, hypoglycemia, anaphylaxis, angioneurotic edema, and bullous rashes(including erythema multiforme, Stevens-Johnson syndrome, and toxicepidermal necrolysis). In some embodiments, side effects are partiallyeliminated. As used herein, the phrase partially eliminated refers to areduction in the severity, extent, or duration of the side effect of atleast 25%, 50%, 75%, 85%, 90%, or preferably 95%. In some embodiments,side effects are completely eliminated. Those skilled in the art arecredited with the ability to detect and grade the severity, extent, orduration of side effects as well as the degree of amelioration of a sideeffect. In some embodiments, two or more side effects are ameliorated.

In some embodiments, the methods of the present invention minimize GIside effects or hepatobiliary side effects. In some embodiments, themethods minimize at least one of steatorrhea, abdominal cramping,distention, elevated liver function tests, minor fatty liver; hepaticfat build up, polyneuropathy, peripheral neuropathy, rhabdomyolysis,arthralgia, myalgia, chest pain, rhinitis, dizziness, arthritis,peripheral edema, gastroenteritis, liver function tests abnormal,colitis, rectal hemorrhage, esophagitis, eructation, stomatitis, biliarypain, cheilitis, duodenal ulcer, dysphagia, enteritis, melena, gumhemorrhage, stomach ulcer, tenesmus, ulcerative stomatitis, hepatitis,pancreatitis, cholestatic jaundice, paresthesia, amnesia, libidodecreased, emotional lability, incoordination, torticollis, facialparalysis, hyperkinesia, depression, hypesthesia, hypertonia, legcramps, bursitis, tenosynovitis, myasthenia, tendinous contracture,myositis, hyperglycemia, creatine phosphokinase increased, gout, weightgain, hypoglycemia, anaphylaxis, angioneurotic edema, and bullous rashes(including erythema multiforme, Stevens-Johnson syndrome, and toxicepidermal necrolysis).

In some embodiments, minimization of one or more side effects occurswithin 2 weeks of initiation of treatment. In some embodiments,minimization of the one or more side effects occurs within 3 weeks ofinitiation of treatment.

In some embodiments the minimization of the side effect is determined byassessing the grade, severity, extent, or duration by subjectquestionnaire.

The present invention also provides methods for inhibiting MTP in asubject while reducing side effects comprising administering to thesubject an amount of an MTP inhibitor effective to inhibit MTP. In someembodiments, the MTP inhibitor is administered orally.

The present invention further provides a kit for treating a disorderassociated with hyperlipidemia and/or hypercholesterolemia in a subject.In some embodiments the kit comprises at least three sets of dosageunits of an MTP inhibitor, wherein a first set of dosage units provides0.03 mg/kg/day for a first interval, a second set of dosage unitsprovides 0.1 mg/kg/day for a second interval, and a third set of dosageunits provides 0.3 mg/kg/day for a third interval; and b) instructionsfor use. In some embodiments, the kit further comprises a fourth set ofdosage units, said fourth set providing 1.0 mg/kg/day for a fourthinterval. In some embodiments, the kit further comprises a container forstoring the sets of dosage units according to a schedule foradministration.

In some embodiments, the kit comprises a first set of dosage unitsproviding 6.25 mg/day for a first interval, a second set of dosage unitsproviding 12.5 mg/day for a second interval, a third set of dosage unitsproviding 25 mg/day for a third interval, a fourth set of dosage unitsproviding 37.5 mg/day for a fourth interval, and a fifth set of dosageunits providing 50 mg/day for a fifth interval.

Each set of dosage units comprises sufficient dosage units to administera desired dosage to the subject for the duration of the period for thespecific dose. For example, if a dosage level of 25 mg/day is to beadministered to the subject for 2 weeks, the set of dosage units for the25 mg/day may include 14 dosage units of 25 mg. Alternatively, the setmay include 70 dosage units of 5 mg.

In some embodiments the kit further comprises one or more further lipidmodifying compounds for the treatment of a disorder associated withhyperlipidemia and/or hypercholesterolemia.

For oral administration, the pharmaceutical compositions of the presentinvention may take the form of solid dose forms, for example, tablets(both swallowable and chewable forms), capsules or gelcaps, prepared byconventional means with pharmaceutically acceptable excipients andcarriers such as binding agents (e.g. pregelatinised maize starch,polyvinylpyrrolidone, hydroxypropylmethylcellulose and the like),fillers (e.g. lactose, microcrystalline cellulose, calcium phosphate andthe like), lubricants (e.g. magnesium stearate, talc, silica and thelike), disintegrating agents (e.g. potato starch, sodium starchglycollate and the like), wetting agents (e.g. sodium laurylsulphate)and the like. Such tablets may also be coated by methods well known inthe art.

The dose administered may be adjusted according to age, weight andcondition of the patient, as well as the route of administration, dosageform and regimen and the desired result. In some embodiments, dosesadministered to the subject are titrated until a desired endpoint isreached.

Preparation and formulations of the inhibitors are disclosed infra,supra, and in Canadian Patent Application Ser. No. 2,091,102; U.S.application Ser. No. 117,362; WO 92/26205 published Aug. 29, 1996; U.S.application Ser. No. 472,067, filed Jun. 6, 1995; U.S. application Ser.No. 548,811, filed Jan. 11, 1996; U.S. provisional application Ser. No.60/017,224, filed May 9, 1996; U.S. provisional application Ser. No.60/017,253, filed May 10, 1996; U.S. provisional application Ser. No.60/017,254, filed May 10, 1996; U.S. provisional application Ser. No.60/028,216, filed Oct. 1, 1996; U.S. Pat. Nos. 5,595,872, 5,712,279;5,739,135; 5,789,197, 5,883,109, and 6,066,653. All of the above,including structures, are incorporated herein by reference.

For oral administration, a satisfactory result may be obtained employingthe MTP inhibitor in a daily amount within the range of from about 0.01mg/kg to about 100 mg/kg and preferably from about 0.1 mg/kg to about 75mg/kg, one to four times daily.

For parenteral administration, the MTP inhibitor may be employed in adaily amount within the range of from about 0.005 mg/kg to about 10mg/kg and preferably from about 0.005 mg/kg to about 8 mg/kg, one tofour times daily.

Additional lipid modifying compounds, when present, may be employed indosages normally employed as indicated in the Physician's DeskReference, for each of such agents such as in an amount within the rangeof from about 2 mg to about 7500 mg, from about 2 mg to about 4000 mg,or from about 10 mg to about 5000 mg.

The MTP inhibitor and other lipid modifying compounds may be employedtogether in the same oral dosage form or in separate oral dosage formstaken at the same time.

The compositions described above may be administered in the dosage formsas described above in single or divided doses of one to four timesdaily.

Dosage units including tablets, capsules and caplets, of various sizescan be prepared, e.g., of about 2 to 10000 mg in total weight,containing one or both of the active substances in the ranges describedabove, with the remainder being a physiologically acceptable carrier ofother materials according to accepted pharmaceutical practice. Thesetablets can, of course, be scored to provide for fractional doses.Gelatin capsules can be similarly formulated.

In some embodiments, the MTP inhibitor and other lipid modifyingcompounds are provided in the same dosage unit in the form of adivisible dosage unit. For example, in some embodiments a scored tabletmay provide the dosage unit. Under the direction of a physician or othermedical professional, the subject may be directed to take one portion ofthe dosage unit, wherein the one portion will provide the desired dosagelevel for given interval. At the following interval, the patient may beinstructed to take two or more portions of the dosage unit wherein thetwo or more portions will provide the desired dosage level for thatinterval.

Liquid formulations can also be prepared by dissolving or suspending oneor the combination of active substances in a conventional liquid vehicleacceptable for pharmaceutical administration so as to provide thedesired dosage in one to four teaspoonfuls.

Such dosage forms can be administered to the patient on a regimen of oneto four doses per day.

According to some embodiments, in order to more finely regulate thedosage schedule, the active substances may be administered separately inindividual dosage units at the same time or carefully coordinated times.Since blood levels are built up and maintained by a regulated scheduleof administration, the same result is achieved by the simultaneouspresence of the two substances. The respective substances can beindividually formulated in separate unit dosage forms in a mannersimilar to that described above.

Fixed combinations of MTP inhibitors and other lipid modifying compoundsare more convenient and are preferred, especially in tablet or capsuleform for oral administration.

In formulating the compositions, the active substances, in the amountsdescribed above, are compounded according to accepted pharmaceuticalpractice with a physiologically acceptable vehicle, carrier, excipient,binder, preservative, stabilizer, flavor, etc., in the particular typeof unit dosage form.

Illustrative of the adjuvants which may be incorporated in tablets arethe following: a binder such as gum tragacanth, acacia, corn starch orgelatin; an excipient such as dicalcium phosphate or cellulose; adisintegrating agent such as corn starch, potato starch, alginic acid orthe like; a lubricant such as stearic acid or magnesium stearate; asweetening agent such as sucrose, aspartame, lactose or saccharin; aflavoring agent such as orange, peppermint, oil of wintergreen orcherry. When the dosage unit form is a capsule, it may contain inaddition to materials of the above type a liquid carrier such as a fattyoil. Various other materials may be present as coatings or to otherwisemodify the physical form of the dosage unit. For instance, tablets orcapsules may be coated with shellac, sugar or both. A syrup of elixirmay contain the carrier, glycerol as solubilizer, sucrose as sweeteningagent, methyl and propyl parabens as preservatives, a dye and aflavoring such as cherry or orange.

Some of the active substances described above form commonly known,pharmaceutically acceptable salts such as alkali metal and other commonbasic salts or acid addition salts, etc. References to the basesubstances are therefore intended to include those common salts known tobe substantially equivalent to the parent compound.

The formulations as described above will be administered for a prolongedperiod, that is, for as long as the acid lipase deficiency exists.Sustained release forms of such formulations which may provide suchamounts biweekly, weekly, monthly and the like may also be employed.

The following examples are meant to illustrate the invention and are notto be construed to limit the invention in any way. Those skilled in theart will recognize modifications that are within the spirit and scope ofthe invention.

EXAMPLES Example 1

Formulations suitable for oral administration are prepared as describedbelow.

Capsules containing 1 mg MTP inhibitor BMS 201,038 and capsulescontaining 50 mg BMS 201,038 are produced from the followingingredients.

1 mg capsule 50 mg capsule Amt (mg/ Amt (mg/ capsule) capsule)BMS-201038* 1.1 56.9 Lactose, Hydrous, NF ca. 30.2 ca. 99.9 Lactose,Anhydrous, NF 47.3   0.0 Microcrystalline Cellulose, NF 10.0  50.0Pregelatinized Starch, NF 5.0 25.0 Sodium Starch Glycolate, NF 5.0 12.5Colloidal Silicon Dioxide, NF 1.0  5.0 Magnesium Stearate, NF 0.3  0.6Purified Water, USP or q.s. q.s. Water for Injection, USP q.s. q.s.Gray, Opaque, Size #0 One Capsule One Capsule Total Fill Weight 100.0 250.0  *In the 1 mg capsule this amount is expressed in terms of theamount of methane sulfonic acid salt per capsule at 100% potency. In the50 mg capsule, this amount is expressed in terms of the free base Thisis equivalent to 1 mg and 50 mg (1 mg capsule and 50 mg capsule,respectively) of the free base.

The MTP inhibitor BMS 201,038, and colloidal silicon dioxide are blendedin a suitable blender with lactose hydrous, microcrystalline cellulose,pregelatinized starch and a portion of sodium starch glycolate. Theresulting blend is wet granulated with water. The wet granulation isdried in a suitable dryer. The remaining portion of sodium starchglycolate is added to the granulation and mixed therein. Magnesiumstearate is added to the granulation and mixed therein. The resultingblend is filled into capsules.

Example 2

Pravastatin tablets (10, 20 or 40 mg as described in the 2004 PDR) andMTP inhibitor (BMS 201,238) tablets may be administered as a combinationin accordance with the teachings of the present invention. In addition,the pravastatin and MTP inhibitor tablets may be ground up into powdersand used together in a single capsule.

Example 3

Simvastatin tablets (10, 20 or 40 mg as described in the 2004 PDR) andMTP inhibitor (BMS 201,238) tablets may be administered as a combinationin accordance with the teachings of the present invention. In addition,the simvastatin and MTP inhibitor tablets may be ground up into powdersand used together in a single capsule, caplet or tablet.

Example 4

Ezetimibe tablets (10 mg as described in the 2004 PDR) and MTP inhibitor(BMS 201,238) tablets may be administered as a combination in accordancewith the teachings of the present invention. In addition, the ezetimibeand MTP inhibitor tablets may be ground up into powders and usedtogether in a single capsule, caplet or tablet.

Example 5

Tablets containing 500 mg clofibrate by itself or in combination with 10mg BMS 201,038 may be employed in separate dosage forms or combined in asingle capsule form.

Example 6

To evaluate pharmacodynamic readouts of treatment according to thepresent invention, the effects of treatment with BMS-201038 at 4 doselevels (0.03, 0.1, 0.3, and 1.0 mg/kg body weight) on nutritionalstatus, hepatic fat content and pulmonary function can be determined by:

-   -   (a) Hepatic fat content as measured by MR1\nuclear magnetic        resonance spectroscopy (NMRS);    -   (b) Pulmonary function as measured by spirometry with DLCO;    -   (c) Nutritional status as measured by serum levels of fat        soluble vitamins A, D, and E;    -   (d) international normalized ratio (INR) to evaluate vitamin K        status; and plasma phospholipid inoleic acid, arachidonic acid,        alpha linolenic acid and eicosapentaenoic acid by gas liquid        chromatography to assess essential fatty acid intake.

Example 7

Twenty (20) subjects are randomized in a 3:1 ratio to BMS-201038 (n=15)or placebo (n=5) in a double-blind fashion for 11-15 weeks depending onweight as described below. At the end of 11 or 15 weeks, BMS-assignedsubjects will continue taking the maximum tolerated dose for theremaining study (through week 39). For BMS-201038-treated patients,study drug will be initiated at 6.25 mg/d for 1 week and then will betitrated up to 12.5 mg/day for 2 weeks followed by 25 mg/day for 4 weeksand then to 50 mg/day for 4 weeks. BMS-201038 treated subjects whoseweight is between 62.5 and 74.9 kg will titrate up to 62.5 mg/day for anadditional 4 weeks. BMS-201038-treated subjects whose weight is ≥75 kg,will titrate up from 50 mg to 75 mg/day for an additional 4 weeks.Subjects who weight is <62.5 kg will remain at 50 mg/d (or the maximumtolerated dose) for the remaining 28 weeks. Subjects who titrate up to62.5 mg/d or 75 mg/day will remain at this dose (or the maximumtolerated dose) for the remaining 24 weeks.

Subjects randomized to placebo will take matching placebo for 15 weeks.After this time period, placebo-treated subjects will start takingBMS-201038 following the same schedule as outlined above for theoriginal BMS-201038-treated subjects. After the dose titration scheduleis complete at week 26 or 30 depending on weight, subjects will take themaximum tolerated dose for the remaining study (through week 39) so thatthe entire study for all subjects will be 39 weeks in duration.

Example 8

The tolerability and thus the effectiveness of BMS-201038 appears to bedependent on the dosing regimen. In a phase II study using BMS-201038 inpatients with primary hypercholesterolemia, a dosage of 25 mg per dayfor 4 weeks produced clinically significant gastrointestinal (GI)steatorrhea, abdominal cramping and distention) and statisticallysignificant hepatobiliary (elevated liver function tests and minor fattyliver) symptoms in some patients receiving study drug. It appeared thatthe degree of both GI-related symptoms and hepatic fat were in part dueto the study design, particularly the dosing regimen. BMS-201038 is apotent inhibitor of both intestinal and hepatic microsomal triglyceridetransfer protein (MTP). While lack of adequately controlling dietary fatintake most likely contributed to GI-related symptoms, it is possiblethat providing a starting dose of 25 mg/day also contributed. Startingat a low dose and titrating up slowly may improve GI-relatedtolerability as well as provide time for the liver to adjust to theinhibition of MTP, perhaps decreasing hepatic fat build up. This theorywas applied in designing a study investigating the safety, tolerabilityand efficacy of BMS-201038 in patients with homozygous familialhypercholesterolemia (hoFH).

Six patients with hoFH were enrolled and completed the study perprotocol. Subjects received once daily dosing of 4 doses of BMS-201038(0.03, 0.1, 0.3 and 1.0 mg/kg) for 4 weeks at each dose. We chose aninitial low dose (0.03 mg/kg) that while not expecting to beefficacious, would be a dose that would be expected to be safe and welltolerated (˜2.1 mg in the 70 kg man) The remaining three doses werechosen by calculating ½ log units of the previous dose. We picked anupper dose of 1 mg/kg based on data from the animal study by Wetterauand colleagues revealing greater than 80% LDL cholesterol reductionusing 10 mg/kg, with an ED₅₀ of 1.9 mg/kg. All 6 subjects tolerated thedrug up to the maximal 1 mg/kg dose with little to no steatorrhea.Although all subjects had evidence of dose-dependent increases inhepatic fat by NMRS, the increase from baseline to 4 weeks on 1 mg/kgwas varied with a range of 3-37%. Three of 6 subjects experiencedsubstantial increases in liver transaminases, but only 1 subject had apersistent increase that required a temporary dose reduction. Thissubject also had the greatest increase in hepatic fat which may havebeen exacerbated by the large consumption of alcohol on a regular basis.At the two highest doses, the mean percent changes in lipids among the 6subjects were: total cholesterol −30±9% and −58±8.5%, non-HDLcholesterol −31±9% and −60±8.8%, and apoB −15±16% and −55±13%,respectively. These data indicate that symptoms of steatorrhea andhepatic fat can be significantly reduced by initiating a low dose with agradual up titration.

Each of the patents, patent applications, references and publicationsdescribed herein is hereby incorporated by reference in its entirety.

Various modifications of the invention, in addition to those describedherein, will be apparent to those of skill in the art in view of theforegoing description. Such modifications are also intended to fallwithin the scope of the appended claims.

What is claimed is:
 1. A method of treating a subject suffering fromfamilial chylomicronemia syndrome, comprising: administering to thesubject an effective amount of an MTP inhibitor of the followingformula:

or a pharmaceutically acceptable salt thereof, or the piperidine N-oxidethereof, wherein said administering of the MTP inhibitor comprises atleast two step-wise, increasing dose levels of the MTP inhibitor,wherein each of the dose levels is no more than 50% of the immediatelyfollowing dose level.
 2. The method of claim 1, wherein the first doselevel is sub-therapeutic.
 3. The method of claim 1, further comprisingadministering a third dose level of the MTP inhibitor, wherein thesecond dose level is no more than 50% of the third dose level.
 4. Themethod of claim 3, wherein each of the first and second dose levels areadministered about 7 to about 35 days.
 5. The method of claim 3, whereinthe first dose level is administered for about 2 weeks and the seconddose level is administered for about 4 weeks.
 6. The method of claim 1,wherein the third dose level is about 0.2 to about 0.59 mg/kg/day. 7.The method of claim 1, wherein said administering reduces low-densitylipoprotein cholesterol levels of the subject at least 30% as comparedto control blood levels.
 8. The method of claim 7, wherein saidadministering reduces total cholesterol levels of the subject at least30% as compared to control blood levels.
 9. The method of claim 8,wherein said administering reduces apolipoprotein B levels of thesubject by at least 30% as compared to control blood levels.
 10. Themethod of claim 9, wherein said administering reduces triglyceridelevels of the subject at least 30% as compared to control blood levels.11. The method of claim 7, wherein said administering reducesapolipoprotein B levels of the subject by at least 30% as compared tocontrol blood levels.
 12. The method of claim 11, wherein saidadministering reduces triglyceride levels of the subject at least 30% ascompared to control blood levels.
 13. The method of claim 7, whereinsaid administering reduces triglyceride levels of the subject at least30% as compared to control blood levels.
 14. The method of claim 13,wherein a second dose level ranges from about 5-30 mg/day.
 15. Themethod of claim 14, further comprising a third dose level ranging fromabout 10-50 mg/day.
 16. The method of claim 1, wherein saidadministering reduces total cholesterol levels of the subject at least30% as compared to control blood levels.
 17. The method of claim 16,wherein said administering reduces apolipoprotein B levels of thesubject by at least 30% as compared to control blood levels.
 18. Themethod of claim 17, wherein said administering reduces triglyceridelevels of the subject at least 30% as compared to control blood levels.19. The method of claim 16, wherein said administering reducestriglyceride levels of the subject at least 30% as compared to controlblood levels.
 20. The method of claim 1, wherein said administeringreduces apolipoprotein B levels of the subject by at least 30% ascompared to control blood levels.
 21. The method of claim 20, whereinsaid administering reduces triglyceride levels of the subject at least30% as compared to control blood levels.
 22. The method of claim 1,wherein said administering reduces triglyceride levels of the subject atleast 30% as compared to control blood levels.
 23. The method of claim1, wherein said administering minimizes side effects as compared toadministration of the MTP inhibitor to a subject at a starting dose of25 mg/day.
 24. The method of claim 1, wherein a first dose level rangesfrom about 2-13 mg/day.